Specialized Nutrition Support

Aka: Specialized Nutrition Support, Nutrition Support, Nutritional Support

1. See Also
   1. Subjective Global Assessment of Nutritional Status
   2. Enteral Nutrition
   3. Total Parenteral Nutrition
   4. Refeeding Syndrome
   5. Malnutrition
   6. Nutrition in the Intensive Care Unit
2. Defintions
   1. Nutritional Support Therapy
      1. Formulated enteral or parenteral nutrients given to Restore nutritional status
   2. Enteral Nutrition
      1. Gastrointestinal Tract delivery of Nutritional Support
   3. Parenteral Nutrition
      1. Intravenous delivery of Nutritional Support
3. Indications
   1. No food intake secondary to underlying condition (adjusted for malnourishment at baseline)
      1. Adults: 5-7 days
      2. Children: 3-5 days
      3. Infants: 1-3 days
   2. Specific conditions
      1. See Nutrition in the Intensive Care Unit
      2. Impaired bowel function (e.g. short bowel syndrome)
      3. Severe prolonged hypercatabolic state
      4. Severe Protein-calorie Malnutrition (due to a treatable condition)
      5. Prolonged bowel rest (e.g. Inflammatory Bowel Disease exacerbation)
4. Types
   1. Enteral Nutrition
      1. Prefererred form of Nutritional Support
   2. Peripheral Parenteral Nutrition (PPN)
   3. Total Parenteral Nutrition (TPN)
5. Evaluation: General Evaluation
   1. See Subjective Global Assessment of Nutritional Status
   2. See Lab Markers of Malnutrition
   3. See Nutrition in the Intensive Care Unit
   4. Hospitalized Patient Nutrition Assessments
      1. Malnutrition Screening Tool
         1. https://static.abbottnutrition.com/cms-prod/abbottnutrition-2016.com/img/Malnutrition%20Screening%20Tool_FINAL_tcm1226-57900.pdf
      2. Nutrition Risk Screening
         1. https://www.mdcalc.com/nutrition-risk-screening-2002-nrs-2002
      3. Short Nutritional Assessment Questionnaire
         1. https://www.fightmalnutrition.eu/toolkits/summary-screening-tools
   5. Nutrition Care Process Framework (Registered Dietitian Nutritionist)
      1. Anthropometric measurement
      2. Biochemistry results and other test results
      3. Food and nutrition history
      4. Related Patient Medical history (including significant comorbidities)
      5. Nutrition focused physical exam
6. Evaluation: Nutritional requirements
   1. Calories
      1. Child >5 years: 1500 kcal/day for weight of 20kg, then 25 kcal/day per each additional kg above 20 kg
      2. Adults: 25-35 kcal/kg/day
      3. Adults: Mifflin-St Jeor Equation (KCals/day or RMR)
         1. Males = 9.99 * wtKg + 6.25 * htCm - 4.92 * ageY + 5
         2. Females = 9.99 * wtKg + 6.25 * htCm - 4.92 * ageY -161
   2. Protein
      1. Adults: 0.8 to 1.5 g/kg/day
      2. Higher Protein indications
         1. All Children and infants, as well as those adults in hypercatabolic or Protein losing states
         2. Bariatric Surgery (1 to 1.5 g/kg/day using Ideal Body Weight)
         3. Hemodialysis (1.2 to 1.5 g/kg/day)
         4. Critical Illness (1.2 to 2.0 g/kg/day)
         5. Obesity (2 to 2.5 g/kg/day)
         6. Pressure Ulcer (1.2 to 1.5 g/kg/day)
         7. Respiratory Disease (1.2 to 1.6 g/kg/day to maintain; increase to 1.6 to 2.0 for repletion)
   3. Fluid
      1. Fluid 1 ml/kcal OR
      2. Fluid 1500 ml per BSA (m2) OR
      3. Age based
         1. Age 16 to 30 years old: 35 to 40 ml/kg
         2. Age 31 to 54 years old: 30 to 35 ml/kg
         3. Age 55 to 65 years: 30 ml/kg
         4. Age >65 years: 25 ml/kg
   4. Other nutrients
      1. Linoleic Acid
         1. Dose: 2-4% of total calories should be in this form to prevent Essential Fatty Acid deficiency
7. Prcautions
   1. Refeeding Syndrome risk
      1. Start refeeding at one third or less of nutritional needs and gradually increase every 5-7 days
8. References
   1. Kulick (2011) Am Fam Physician 83(2): 173-83 [PubMed]
   2. Lesser (2021) Am Fam Physician 104(6): 580-8 [PubMed]